A GRS quandary

Note that this post contains discussion of trans-related surgery and sexual activity.

A little digression on terminology to start with. Three abbreviations are commonly used to refer to operations like vaginoplasty and phalloplasty that are used to transform the external genitalia of trans people. (Not all trans people require surgery, and some who want surgery are unable to have it for a variety of reasons.)

SRS (sex reassignment surgery). I find this problematic because while sex (or gender) is customarily assigned at birth, this is an erroneous assignment in the case of trans people. Though considered male when I was born, I am in fact female (or potentially non-binary depending on how much fuzziness we allow in our arbitrary categories). Surgery of any kind isn’t going to change that. My sex was essentially reassigned when I told people that I am a woman.

GCS (gender confirmation surgery). I used to think this was less problematic, but does the reconfiguration of someone’s genitals really confirm their gender? Isn’t that just biological essentialism? So, no.

GRS (gender reassignment surgery). Um. Isn’t that just like SRS? Let’s try that again:

GRS take 2 (genital reconstruction/reconfiguration/recycling surgery). That’s more like it. It just says what it is. When I say GRS, this (or something like it) is what I mean.

Brighton comes to Glasgow

Anna standing pensively next to a sign reading ‘Nuffield Health Glasgow Hospital’
About to meet my surgeon for the first time

I haven’t really written about surgery before, except in passing, in a couple of unposts. Early this year, I had appointments with the two psychiatrists who were required to give opinions on my suitability for GRS. Both were happy that I met their criteria. Eventually, a referral was made to the private hospital in Brighton, in England, where all Scottish NHS vaginoplasty patients are currently treated.

On 13 September, I took the train to Glasgow to meet the surgeon who will perform my operation. Accompanied by two nurses, he had flown up from Brighton the night before to meet his latest group of Scottish patients – and the three of them would fly back later that day.

The private healthcare environment was an eye-opener: someone I could imagine working in a fancy hotel escorted me to a pleasant waiting room, in which I could help myself to free coffee and posh biscuits! As far as I could tell, six patients in all were being seen, and we were taken in groups of three by one of the nurses to be given some general information about the surgery.

The nurse

The nurse spoke about the hospital we’d be staying in, what would happen on each day of our stay, and what we’d need to do before and, in particular, after the surgery. She also showed us photographs of a number of vulvas created by the surgeon. All of them looked good to me, which is just as well because we don’t get any choice about the aesthetics! But then again, I have only had encounters with one vulva/vagina in my adult life, so I don’t have a lot to go on.

We were given forms to fill in, detailing aspects of our medical history. There was also some paperwork relating to consent and a form relating to (eventual) application for a gender recognition certificate. That was particularly awkward because I had to inform them of my deadname (the name I was given at birth), which I didn’t feel was something they really needed to know. Hmm.

Additionally, we were given surgery information packs with consent forms for specific surgery to be carried out, to be returned by post after a period of reflection. There were two different packs. One was for full vaginoplasty (the shortening and repositioning of the urethra, the creation of labia and a clitoris, and the formation of a vagina). The other was for ‘cosmetic’ vulvoplasty, which includes everything except the creation of a vagina.

I had gone into the appointment pretty certain that I wanted a vagina, but after the session with the nurse, I decided to take both packs away and give it some more thought. (Herein lies my quandary.)

The surgeon

As we were filling in our medical histories, the three of us were called one at a time to see the surgeon. I was second. I was forewarned about his brusque, matter-of-fact manner, so that didn’t bother me too much. He was mainly concerned that I knew exactly what I was signing up for, so that I’d be able to give informed consent.

He also had to examine me to see whether I would need hair removal from parts of my skin that will end up lining my vagina (should I choose to have one). I’m not sure exactly what he did, but it was just a few seconds of uncomfortable stretching of my penis, following which he (brusquely) announced that he’d be able to do simple penile inversion and that I wouldn’t require hair removal.

(In the pack that I took away with me, there was a leaflet explaining the hair removal required if a technique called penoscrotal inversion is performed, in which a flap of scrotal tissue running from the perineum to the underside of the penis is used in addition to the skin of the penis itself to create the neovagina.)

I will need to stop HRT (to avoid deep vein thrombosis) four weeks before surgery (two weeks later than people using oral HRT). The surgeon said that although he couldn’t be certain when the surgery would actually take place, he thought it would be within six to twelve months. Hair removal by electrolysis (which I thought I would need) could easily have taken a year or more, so this was excellent news!

The quandary

I now need to sign my consent form and post it back to the hospital in Brighton. But which form? There’s a different one in each pack that I took away with me. Things seem so much less clear than they did before.

Full vaginoplasty requires a seven-day stay in hospital, two days more than for cosmetic vulvoplasty. But this is obviously a minor concern.

Vaginoplasty, being more invasive than vulvoplasty, carries additional risks of complications, but these are very small, so I don’t feel I need to take those into account.

In the short term, vulvoplasty has the advantage of a faster recovery (perhaps three weeks before returning to normal activities, as opposed to six to eight weeks for vaginoplasty – these are all rough figures). In either case, the first two weeks after the operation will be spent in the confines of my flat, and I will probably need to call on people to assist me with everyday tasks during that time.

None of these things make a huge difference (though obviously vulvoplasty has the edge at this point).

Maintenance

A neovagina created using penile inversion requires a substantial lifelong commitment. In particular, it needs to be dilated regularly (three times a day at first, but eventually just once or twice a week, I believe). Without dilation, the vagina would narrow and may become prone to infection.

I don’t know how onerous a task this is in practice, and I would be really interested to hear the views of those who have had this surgery. How does it compare to the other things we do as part of our daily routine?

(There are other vaginoplasty techniques, which use different source material for the vaginal lining. Some of these create a neovagina that doesn’t require regular dilation. However, these aren’t an option for me: I have to take what I’m offered by the NHS. That’s probably just as well, or I’d have even more choices to make!)

I am also a little concerned about what would happen if I were to be incapacitated in some way later in life and needed someone to look after me. It’s not something I really like to think about, but I imagine that having a dilation regime to maintain could become awkward, at the very least.

Everything I’ve written so far makes vaginoplasty seem like a pretty poor choice. There must be some positives, surely.

Sex, mainly

One reason to choose it is that it might make me feel more complete. This is impossible for me to know at this stage. But if I opted for cosmetic vulvoplasty instead, I would never know, and I would never have the option of having a vagina retrofitted at a later date. Sometimes, I do have a vague sensation of something that could be a vagina. (But if I can have a vague sensation of it now, I could still have a vague sensation of it after surgery, without there being a vagina.)

Aside from the sense of completeness I might (or might not) feel, what practical use would I have for a neovagina? Possibilities include:

  • penetrative sex involving a partner with a penis or using a dildo
  • manual stimulation by a partner
  • masturbation (using a dildo or manual stimulation)
  • prostate examination (!).

The last of these is clearly a bonus, but perhaps not worth the trouble of lifelong dilation on its own!

The other three (and probably many more that my imagination doesn’t extend to) relate to sexual arousal, and again I can’t possibly know what this will be like. I’d love to hear more about the sexual experiences of people who have had either form of surgery (without wishing to be prurient in any way).

There are various complicating factors.

I may be asexual (or just sex-repulsed?), to some degree anyway. I have never been that interested in sex. My only sexual relationship was with my ex-wife, and that was sporadic. It’s not that I had a particularly low libido (though I currently have next to none!), but masturbation, fraught with unpleasantness in some respects, provided an easier release for me than the messiness and sensory confusion of sexual intercourse. I never understood the popular description of people as ‘sexy’.

But what if I’m not really asexual? Or what if surgery gives me a different perspective? Then the presence or absence of a vagina could suddenly take on a new importance – and wouldn’t it be better to have a vagina without any particular need for one than to find myself regretting the absence of a vagina? How many people regret having cosmetic vulvoplasty, I wonder?

Thinking of masturbation for now, how important is the vagina likely to be for that (assuming my libido increases to a detectable level)? I’d still have a clitoris in either case – and other parts of my body, such as nipples, should in theory become erogenous. (Or should they be already?)

What if I find myself attracted to someone with a penis, who may wish to have penetrative sex? That’s not something that appeals to me at the moment, but I don’t know whether I can safely rule it out.

Since I consider myself to be lesbian-leaning (with a little bit of bi-/panromantic in the mix), if I were to have a sexual (or occasionally sexual) relationship with another woman (cis or trans), what would that actually look like? I have so little sexual experience that this takes me completely out of my depth!

And in all of this talk of potential sexual relationships (which I’d obviously prefer to avoid if I do find that I’m asexual), what are the chances of me actually ending up in such a relationship? Perhaps masturbation should be the deciding factor. Is vaginoplasty worth it for that?

Advice needed

As you can tell, I am desperately confused and in need of informed advice. I’d love to hear from trans women or non-binary people who have had either form of GRS. I’d particularly like to hear from people who are (or thought they were) asexual. And I’d really appreciate input from people who are also autistic or otherwise neurodivergent.

Please do leave comments on this post if you are happy to do so, contact me directly if you would rather do that, or DM me (@axnicho) on Twitter.

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